Provider Demographics
NPI:1003981903
Name:SUDBURY RACQUET CLUB INC.
Entity Type:Organization
Organization Name:SUDBURY RACQUET CLUB INC.
Other - Org Name:THE LONGFELLOW CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:508-358-7355
Mailing Address - Street 1:524 BOSTON POST RD
Mailing Address - Street 2:THE LONGFELLOW CLUB
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-1833
Mailing Address - Country:US
Mailing Address - Phone:508-358-7355
Mailing Address - Fax:508-358-3525
Practice Address - Street 1:524 BOSTON POST RD
Practice Address - Street 2:THE LONGFELLOW CLUB
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-1833
Practice Address - Country:US
Practice Address - Phone:508-358-7355
Practice Address - Fax:508-358-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA763282OtherTUFTS
MALG0023OtherBLUE CROSS BLUE SHIELD
MA5582051OtherAETNA
MA6300209OtherUNITED HEALTH CARE
MA39411OtherHARVARD PILGRIM HEALTH
MA5582051OtherAETNA